The Psychiatric Medical The Psychiatric Medical Home and Chronic Home and Chronic Psychiatric IllnessPsychiatric Illness

Edward Kim, MD, MBAEdward Kim, MD, MBAAssociate Director, Health Economics and Associate Director, Health Economics and Outcomes Research Outcomes Research BristolBristol--Myers Squibb CompanyMyers Squibb Company

OverviewOverview

The challenge of chronic psychiatric The challenge of chronic psychiatric illnessillnessStructural barriers to effective Structural barriers to effective managementmanagementPsychiatric medical home case studyPsychiatric medical home case studyLessons learned/future directionsLessons learned/future directions

The ProblemThe Problem

People with serious mental illness die People with serious mental illness die approximately 25 years earlier than approximately 25 years earlier than the general population.the general population.Medical coMedical co--morbidity is common in this morbidity is common in this populationpopulationCare coordination is complexCare coordination is complex

SMR = standardized mortality ratio (observed/expected deaths).1. Harris et al. Br J Psychiatry. 1998;173:11. Newman SC, Bland RC. Can J Psych. 1991;36:239-245.2. Osby et al. Arch Gen Psychiatry. 2001;58:844-850.3. Osby et al. BMJ. 2000;321:483-484.

Increased Mortality From Medical Increased Mortality From Medical Causes in Mental IllnessCauses in Mental Illness

Increased risk of death from medical causes in Increased risk of death from medical causes in schizophrenia and 20% (10schizophrenia and 20% (10--15 yrs) shorter 15 yrs) shorter lifespanlifespan11

Bipolar and Bipolar and unipolarunipolar affective disorders also affective disorders also associated with higher associated with higher SMRsSMRs from medical from medical causescauses22

––

1.9 males/2.1 females in bipolar disorder1.9 males/2.1 females in bipolar disorder––

1.5 males/1.6 females in 1.5 males/1.6 females in unipolarunipolar

disorderdisorder

Cardiovascular mortality in schizophrenia Cardiovascular mortality in schizophrenia increased from 1976increased from 1976--1995, with greatest 1995, with greatest increase in increase in SMRsSMRs in men from 1991in men from 1991--1995199533

MultiMulti--State Study Mortality Data: State Study Mortality Data: Years of Potential Life LostYears of Potential Life Lost

Compared to the general population, Compared to the general population, persons with major mental illness typically persons with major mental illness typically lose more than 25 years of normal life lose more than 25 years of normal life spanspan

Year AZ MO OK RI TX UT VA (IP only)

1997 26.3 25.1 28.5 1998 27.3 25.1 28.8 29.3 15.5 1999 32.2 26.8 26.3 29.3 26.9 14.0 2000 31.8 27.9 24.9 13.5

Colton CW, Colton CW, ManderscheidManderscheid RW. RW. PrevPrev Chronic Chronic DisDis [serial online] 2006 Apr [date [serial online] 2006 Apr [date cited]. Available from: URL:http://www.cdc.gov/pcd/issues/2006/acited]. Available from: URL:http://www.cdc.gov/pcd/issues/2006/apr/05_0180.htmpr/05_0180.htm

Osby U et al. Schizophr Res. 2000;45:21-28.

Schizophrenia: Schizophrenia: Natural Causes of DeathNatural Causes of Death

Higher standardized mortality rates than the Higher standardized mortality rates than the general population from:general population from:––

Diabetes Diabetes 2.7x2.7x

––

Cardiovascular diseaseCardiovascular disease

2.3x2.3x––

Respiratory diseaseRespiratory disease

3.2x3.2x

––

Infectious diseases Infectious diseases 3.4x3.4x

Cardiovascular disease associated with the Cardiovascular disease associated with the largest number of deaths largest number of deaths ––

2.3 X the largest cause of death in the general 2.3 X the largest cause of death in the general population population

Contributory FactorsContributory Factors

LifestyleLifestyleMedicationsMedicationsSurveillanceSurveillance

Cardiovascular Disease (CVD) Cardiovascular Disease (CVD) Risk FactorsRisk Factors

Modifiable Risk Modifiable Risk FactorsFactors

Estimated Prevalence and Relative Risk (RR)Estimated Prevalence and Relative Risk (RR)

SchizophreniaSchizophrenia Bipolar Bipolar DisorderDisorder

ObesityObesity 4545––55%, 1.555%, 1.5--2X 2X RRRR11 26%26%55

SmokingSmoking 5050––80%, 280%, 2--3X RR3X RR22 55%55%66

DiabetesDiabetes 1010––14%, 2X RR14%, 2X RR33 10%10%77

HypertensionHypertension ≥≥18%18%44 15%15%55

DyslipidemiaDyslipidemia Up to 5X Up to 5X RRRR88

1. Davidson S, et al. Aust N Z J Psychiatry. 2001;35:196-202. 2. Allison DB, et al. J Clin Psychiatry. 1999; 60:215-220. 3. Dixon L, et al. J Nerv Ment Dis. 1999;187:496-502. 4. Herran A, et al. Schizophr Res. 2000;41:373-381. 5. MeElroy SL, et al. J Clin Psychiatry. 2002;63:207-213. 6. Ucok A, et al. Psychiatry Clin Neurosci. 2004;58:434-437. 7. Cassidy F, et al. Am J Psychiatry. 1999;156:1417-1420. 8. Allebeck. Schizophr Bull. 1999;15(1)81-89.

Impact of mental illness on diabetes Impact of mental illness on diabetes managementmanagement

313,586 Veteran Health Authority patients with diabetes 76,799 (25%) had mental health conditions (1999)

Frayne et al. Arch Intern Med. 2005;165:2631-2638

Depression

Anxiety

Psychosis

Mania

Substance use disorder

Personality disorder

0.8 1.0 1.2 1.4 1.6

No HbA test done

0.8 1.0 1.2 1.4 1.6

No LDL test done

0.8 1.0 1.2 1.4 1.6

No Eye examination

done

0.8 1.0 1.2 1.4 1.6

No Monitoring

0.8 1.0 1.2 1.4 1.6

Poor glycemic control

0.8 1.0 1.2 1.4 1.6

Poor lipemic control

Odds ratio for:

““Every system is perfectly designed to Every system is perfectly designed to achieve exactly the results it gets.achieve exactly the results it gets.”” (Berwick, 1998)(Berwick, 1998)

SummarySummary

SPMI population is at high risk for SPMI population is at high risk for medical morbidity and mortalitymedical morbidity and mortalityManagement is suboptimalManagement is suboptimal

Barriers to Effective Barriers to Effective ManagementManagement

Healthcare SystemHealthcare SystemProviderProviderPatientPatient

The MH/SA The MH/SA ““SystemSystem””

Segregated from PH systemSegregated from PH systemDiverse care settingsDiverse care settingsDiverse provider baseDiverse provider baseLack of confidence/priority with Lack of confidence/priority with medical conditionsmedical conditions

System Level BarriersSystem Level Barriers

Structural and functional differences between MH and PH systems reduce

effectiveness and quality of clinical management

MHPMHP PHPPHP

Patient

PCP-Patient Interactions▪

PCP Awareness of needs▪

Patient cognitive barriers▪

Patient health literacy▪

Stigma▪

PCP knowledge of MH system

MHS-PHS Communication▪

HIPAA▪

Geographic/temporal separation▪

Role definition▪

Organizational culture

MHP-Patient Interactions▪

Awareness of needs▪

Role definition▪

Patient cognitive barriers▪

MHP health literacy▪

MHP knowledge of PH system

AccessAccess

to Medical Care of to Medical Care of People with SPMIPeople with SPMI

SPMI clients have difficulties accessing SPMI clients have difficulties accessing primary care providersprimary care providers––

Less likely to report symptomsLess likely to report symptoms

––

Cognitive impairment, social isolation reduce Cognitive impairment, social isolation reduce helphelp--seeking behaviorsseeking behaviors

––

Cognitive, social impairment impedes effective Cognitive, social impairment impedes effective navigation of health care systemnavigation of health care system

Accessing and using primary care is more Accessing and using primary care is more difficultdifficult

Jeste DV, Gladsjo JA, Landamer LA, Lacro JP. Medical comorbidity in schizophrenia. Schizophrenia Bull 1996;22:413-427

Goldman LS. Medical illness in patients with schizophrenia. J Clin Psych 1999;60 (suppl 21):10-15

Management StrategiesManagement Strategies

Care CoordinationCare CoordinationIntegrated CareIntegrated Care

Collaborative Care ModelCollaborative Care Model

Level 1 Level 1 –– Preventive/screeningPreventive/screeningLevel 2 Level 2 –– PCP/extenders provide carePCP/extenders provide careLevel 3 Level 3 –– Specialist consultationSpecialist consultationLevel 4 Level 4 –– Specialist referralSpecialist referral

Katon

et al (2001) Gen Hosp Psychiatry 23:138-144

UMDNJ PilotUMDNJ Pilot

DuallyDually--trained psychiatrist/FPtrained psychiatrist/FP––

Direct patient careDirect patient care

––

Physician of ProtocolPhysician of Protocol

DuallyDually--trained nurse practitionerstrained nurse practitioners––

Direct patient careDirect patient care

––

Education groupsEducation groups––

Liaison with external providers (MH, PH)Liaison with external providers (MH, PH)

UMDNJ PilotUMDNJ Pilot

Full cross-functional integration on-site facilitates optimal

management

MHPMHP PCP/NPPCP/NP

Patient

PCP-Patient Interactions▪

Focused consultation▪

NP follow-up

MHS-PHS Communication▪

Collaboration in treatment team meetings▪

Consultation for routine care▪

Referral for complex cases

MHP-Patient Interactions▪

Focus on MH management▪

Integrate PH issues into care plan

ConclusionsConclusions

CoCo--morbidity and increased mortality are morbidity and increased mortality are the normthe normMultiple barriers prevent effective careMultiple barriers prevent effective careIntegrated care is clinically, operationally Integrated care is clinically, operationally feasiblefeasibleFunding pathway is a major barrierFunding pathway is a major barrier